It is well known that sex hormones affect various cardiovascular risk factors such as body composition, lipids, blood pressure, glucose metabolism, endothelial function, haemostasis, and risk of thrombosis. There are subtle positive and negative changes in cardiovascular risk factors for trans people taking testosterone or oestrogen (for overview: Gooren et al., 2014).

How these changes in cardiovascular risk factors translate into cardiovascular morbidity and mortality is not yet well known. Overall, it is assumed that there is no increased risk of cardiovascular endpoints under the currently prescribed hormonal treatment. Cessation of tobacco use should be strongly recommended to avoid increased risk of thromboembolism and cardiovascular complications (Hembree et al., 2017).

Cardiovascular morbidity and mortality in trans people on oestrogen treatment

Among trans women and other trans people assigned male at birth taking oestrogen, most studies from the past showed an increased risk of cardiovascular morbidity (Asscheman et al., 1989; Van Kesteren et al., 1997, Wierckx et al. 2013) and mortality (Asscheman et al., 2011; Dhejne et al. ., 2011). It should also be borne in mind that the chemical nature of the oestrogen, the route of administration, the cardiovascular health status of the patient, lifestyle factors such as obesity and smoking and the dosage can all exert an influence. In the past, synthetic oestrogen (ethinyl estradiol) was often used in high doses, which is now no longer prescribed. Since a bioidentical oestrogen (estradiolvalerate) started to be prescribed, we are encountering these problems much less.

To reduce cardiovascular risks, a healthy lifestyle with smoking cessation, weight control and sufficient physical activity is recommended to all people taking oestrogen. This should be accompanied by regular health visits and monitoring procedures. Trans persons may hold back from coming forward due to fears that such health conditions might result in withholding of trans related care such as hormone treatment. Health practitioners should reassure trans patients that a holistic approach is being taken that encompasses all their health related needs including transition related care.

For those who have an elevated cardiovascular risk profile or known cardiovascular disease and who are undergoing oestrogen treatment, it is recommended to use transdermal oestrogen therapy (Van Kesteren et al., 1997) and it is not recommended to use ethinyl oestradiol as an oestrogen treatment (Asscheman et al., 2011). The administration through the skin has much less effect on coagulation.

Cardiovascular morbidity and mortality in trans people on testosterone treatment

In contrast to trans people taking oestrogen, most studies show that trans people on testosterone treatment have a lower or similar risk of cardiovascular morbidity and mortality (Asscheman et al., 1989; Van Kesteren et al., 1997; Wierckx et al., 2013; Asscheman et al., 2011; Dhejne et al., 2011). It should be noted that the studies in trans people taking testosterone were conducted on smaller groups and that they were generally younger than the respondents in the studies on trans people taking oestrogen. There is no evidence for an increase in short and midterm cardiovascular adverse outcomes in trans people on testosterone treatment (Gooren & T’Sjoen, 2018; Maraka et al., 2017; van Kesteren et al., 1997).

References:

  • Asscheman H, Gooren LJ, Eklund PL 1989 Mortality and morbidity in transsexual patients with cross-gender hormone treatment. Metabolism 38: 869-873
  • Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ 2011 A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 164: 635-642
  • ​​Dhejne C, Lichtenstein P, Boman M, Johansson A, Langström N, Landén M 2011 Long-term follow-up of transsexuals’ persons undegoing sex reassignment surgery: cohort study in Sweden. PLoS One 6: e16885
  • Gooren LJ, Wierckx K, Giltay E 2014 Cardiovascular disease in transsexual persons treated with cross-sex hormones: reversal of the traditional sex difference in cardiovascular disease pattern. Eur J Endocrinol 1; 170 (6): 809-819
  • Van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ 1997 Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol (Oxf) 47: 337-342
  • Wierckx K, Elaut E, Declerq E, Heylens G, De Cuypere G, Kaufman JM, T’Sjoen G 2013 Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case control study. Eur J Endocrinol 169: 471-478